Drug diversion is certainly not a new issue in the U.S., but it is one that is growing in concern for hospitals and health systems throughout the country. Not only can drug diversion pose a significant threat to the wellbeing of your patients and staff members, but it can also be damaging to the financial and legal security of your organization.
To help work against this, here is a closer look at what exactly drug diversion is, the primary motivations behind it, and some steps health systems can take to proactively plan against it.
What is drug diversion?
Drug diversion is the theft or loss of drugs within a health system, often taking place at the hands of employees within that very system. It typically involves people stealing and taking controlled substances without a prescription, such as nurses with easy access to these drugs. Instead of giving the drugs to a patient, a nurse might take some home to use for themselves or to distribute to another.
Drug diversion can happen at any level of the health system, from operating rooms and clinics to hospital wards and pharmacies – really, anywhere within the health system where access to drugs and the opportunity to divert them exist in tandem.
Why does drug diversion happen?
Generally speaking, there are three things that must be happening at the same time in order for a person to divert drugs.
- First, there is access to controlled substances and an opportunity present to divert.
- Second, there is motivation either from internal (personal distress, physical pain, or drug dependency) or external (family needs, loss of income, or debt) stressors.
- Finally, there is some degree of rationalization that makes it okay for the person to divert drugs. Rationalization can grow out of employee discontent or the perception that the diversion will not be noticed.
We can’t always know what a person is feeling or thinking, so it is incumbent on organizations to have strong internal controls and drug security to reduce the opportunities to divert. The best intentions of health systems can be undermined when staff rely on trust as the number one strategy to prevent diversion.
While drug diversion has been an issue for years, the global pandemic has created new opportunities for diversion by increasing both the level of access to these drugs and the opportunity to divert them.
Why is drug diversion a problem?
Patients are harmed when they don’t receive the prescribed pain relief or receive medications that have been tampered with, leading to serious infections or death.
Caregivers are harmed by faulty judgement of impaired staff and providers, suffering loss of trust in coworkers and other negative emotions.
Hospitals are harmed by non-compliance with federal (CMS) or DEA regulations and potential loss of CMS certification.
Healthcare organizations are harmed by the loss of a good reputation when news of a diversion event hits the press and/or by the reality of class-action lawsuits by patients.
Multi-million-dollar civil penalties and multi-year agreements of DEA oversight following diversion events are expensive and disruptive.
As health systems grow larger, a single case of diversion could become a triggering event for extensive DEA investigations across multiple entities. If diversion happens in one hospital, the DEA is likely to look further, and the risks become even more significant. If you haven’t yet seen signs of drug diversion, it’s not because they don’t exist – it’s because you simply aren’t looking hard enough.
What should you do about drug diversion?
It is important to understand that drug diversion should be on the executive team’s radar. The responsibility to prevent, detect, and manage diversion does not fall entirely on the pharmacy department. Many assume it falls on the shoulders of pharmacy because they have the drugs, but the reality is pharmacy can only control what happens within its own department. There are so many other people touching these controlled substances.
People that manage security, nurses, the HR department, and more all have a role to play – and none of these groups fall under pharmacy. This is why you need a governance structure in place that includes everyone working together – not in silos – to combat drug diversion.
How Visante can help
Visante recommends and can help you to implement four key strategies to manage drug diversion.
- Diversion program structure – A governance committee chaired by leaders, including the DEA registrant, to facilitate interdepartmental collaboration and support for diversion prevention, monitoring, and event management.
- Dedicated diversion resources – A dedicated diversion specialist who can manage analytics, coordinate with a response team, and determine the root causes and solutions when diversion occurs. This is more effective than assigning these duties out to multiple people with several other responsibilities.
- Diversion analytics – Software that merges information from pharmacy, medical records, and more, creating information to show you what staff are doing more effectively than relying on manual audits.
- Diversion playbook – Don’t wait for the next diversion to decide how to manage it. Have a playbook and plan in place for when diversion occurs and how you should respond. The plan should include how to investigate, interview, and intercede on behalf of the individual.
Visante takes a multi-disciplinary approach to diversion management to see how people interact with controlled substances across the entire health system. We have an advantage in understanding how the work happens, how the drugs are prepared and used, and where the risk points lie.
Contact us today to learn more about successfully working against drug diversion within your health system.
Protect patients with shared data about nurses diverting drugs in hospitals
Investigations and findings must be shared, especially with compact states
All too often when a nurse is terminated from a facility for drug diversion there have been multiple infractions. The terminated nurse may test positive for narcotics which were not prescribed, be unable to account for medications that were not given, returned or wasted, or simply did not follow the facility’s medication management policy. These infractions pose a serious problem for the hospital which Is exacerbated when the terminating facility knows that the individual also works at another local healthcare organization.
Unfortunately, this is not an uncommon problem for hospitals in metro areas, especially because there is also a shortage of qualified nurses. Although a complaint is filed with the state’s Board of Nursing, months can pass before the Board investigators contact the originating complainant. That is if an investigator is even assigned. In our experience, the follow up by the Board of Nursing has been inconsistent, leaving the hospital to determine their responsibilities with regard to notifying other employers of the diversion risk on a timely basis. While no one wants to cause someone to lose their job unjustly, it’s critically important, to step in to protect the patient (victim) versus protecting the nurse (diverter). We believe it is important for the Boards of Nursing to establish a strong reporting structure to share this information.
Unique difficulties with compact states
Compact states are those that have adopted the Nursing Licensure Compact (NLC) which is an agreement between states that allow nurses to have one license but the ability to practice in other states that are part of the agreement. While this is an excellent solution to the nursing shortage, it poses an even greater challenge for preventing diversion and sharing information. Some questions to consider are:
- How to ensure that nurses know the laws from each state?
- Which state is responsible for monitoring education, training, investigations and the dissemination of information concerning diversion? It is the state of residency, practice or licensure? For example, in one case a nurse was fired for testing positive to a narcotic that wasn’t prescribed and removing narcotics from the dispensing system without documentation. The hospital from which she was terminated was aware she worked at another local hospital. Although the terminating hospital attempted to warn the Board of Nursing investigator and the Board of Pharmacy, this nurse worked for another year prior to being terminated from the second facility. So, ask yourself, how many patients went without proper pain control during this time period? How many mistakes happened when she was under the influence? Just because a patient did not die does not mean she did not cause great harm to patients. So, when are the nurse’s rights more important than the patients’ rights?
Alarmingly, the compact states do not require federal or state background checks on nurses, allowing for diverting nurses to slip through. There are numerous cases where a nurse practices nationwide while a hospital continues a diversion investigation concerning that individual. Even after felony charges, a nurse may obtain a traveling nurse job in one of the 24 compact states. For instance, a nurse in Wisconsin was fired from a hospital in 2007 for stealing 245 syringes of narcotics. This nurse, during the investigation, obtained a travel nurse job in North Carolina. Six months after arriving he was restricted from working in North Carolina. It took his home state of Wisconsin until 2009 to retract his license.
Opioid addiction is a national epidemic, and supportive resources should be available. Helplines, addiction counselors, support services and hospital resources should address this issue. Outsourced employee assistance programs can be useful, but don’t always provide the proper levels of confidentiality. Investing resources in identifying and treating addiction is part of a sound strategy.
Despite the challenges of addiction and the toll it takes on an individual, it is clearly unacceptable to allow a nurse who is likely diverting to have continued access to medications. It is time to consider allowing terminating hospitals the ability to report the results of an internal drug diversion investigation to future employers and to develop a system for compact states to share the information on a timely basis. In a time of complex computer databases for narcotic prescriptions, criminal charges, and DNA, an up to date and accessible database for nursing licenses should be on the top of our list of priorities. It is our duty to protect our patients and communities from an incapacitated nurse.
Weber T., Ornstein C. Troubled Nurses Skip from State to State Under Compact. ProPublica July 2010.